In daily clinical practice, LV systolic function is routinely assessed with the use of two‐dimensional echocardiography. Using biplane LV end‐diastolic and end‐systolic volumes, LVEF is calculated. ...The introduction of real‐time three‐dimensional echocardiography has improved the accuracy of echocardiographic assessment of LVEF. However, calculated LVEF may not truly represent LV systolic function in specific cardiac diseases or when subtle LV dysfunction is present. Two‐dimensional speckle tracking echocardiography enables assessment of myocardial strain, thereby providing detailed information on global and regional LV deformation. This is of particular interest when subtle LV systolic dysfunction is present despite preserved LVEF. In this review, the potential use of LV global longitudinal strain to detect subtle LV systolic dysfunction is illustrated in various clinical scenarios.
Atrial fibrillation (AF) and stroke are important major health problems that share common risk factors and frequently coexist. Left atrial (LA) remodeling is an important underlying substrate for AF ...and stroke. LA dilation and dysfunction form a prothrombotic milieu characterized by blood stasis and endothelial dysfunction. In addition, alterations of the atrial cardiomyocytes, increase of noncollagen deposits in the interstitial space and fibrosis, favor the occurrence of re-entry that predisposes to AF. Eventually, AF further impairs LA function and promotes LA remodeling, closing a self-perpetuating vicious circle. Multimodality imaging provides a comprehensive evaluation of several aspects of LA remodeling and offers several parameters to identify patients at risk of AF and stroke. How multimodality imaging can be integrated in clinical management of patients at risk of AF and stroke is the focus of the present review paper.
Abstract
Aims
Recurrent mitral regurgitation (MR) has been reported after mitral valve repair for functional MR. However, the impact of recurrent MR on long-term survival remains poorly defined. In ...the present study, mortality-adjusted recurrent MR rates, the clinical impact of recurrent MR and its determinants were studied in patients after mitral valve repair with revascularization for functional MR in the setting of ischaemic heart disease.
Methods and results
Long-term clinical and echocardiographic outcome was evaluated in 261 consecutive patients after restrictive mitral annuloplasty and revascularization for moderate to severe functional MR, between 2000 and 2014. The cumulative incidence of recurrent MR ≥ Grade 2, assessed by competing risk analysis, was 9.6 ± 1.8% at 1-year, 20.3 ± 2.5% at 5-year, and 27.6 ± 2.9% at 10-year follow-up. Cumulative survival was 85.8% 95% confidence interval (CI) 81.0–90.0 at 1-year, 67.3% (95% CI 61.1–72.6%) at 5-year, and 46.1% (95% CI 39.4–52.6%) at 10-year follow-up. Age, preoperative New York Heart Association Class III or IV, a history of renal failure, and recurrence of MR expressed as a time-dependent variable HR 3.28 (1.87–5.75), P < 0.001, were independently associated with an increased mortality risk. Female gender, a history of ST-elevation myocardial infarction, a preoperative QRS duration ≥120 ms, a higher preoperative MR grade, and a higher indexed left ventricular end-systolic volume were independently associated with an increased likelihood of recurrent MR.
Conclusion
Mitral valve repair for functional ischaemic MR resulted in a low incidence of recurrent MR with favourable clinical outcome up to 10 years after surgery. Presence of recurrent MR at any moment after surgery proved to be independently associated with an increased risk for mortality.
Cardiac pacing is the only effective treatment for patients with sick sinus syndrome and atrioventricular conduction disorders. In cardiac pacing, the endocardial pacing lead is typically positioned ...at the right ventricular (RV) apex. At the same time, there is increasing indirect evidence, derived from large pacing mode selection trials and observational studies, that conventional RV apical pacing may have detrimental effects on cardiac structure and left ventricular function, which are associated with the development of heart failure. These detrimental effects may be related to the abnormal electrical and mechanical activation pattern of the ventricles (or ventricular dyssynchrony) caused by RV apical pacing. Still, it remains uncertain if the deterioration of left ventricular function as noted in a proportion of patients receiving RV apical pacing is directly related to acutely induced left ventricular dyssynchrony. The upgrade from RV pacing to cardiac resynchronization therapy may partially reverse the deleterious effects of RV pacing. It has even been suggested that selected patients with a conventional pacemaker indication should receive cardiac resynchronization therapy to avoid the deleterious effects. This review will provide a contemporary overview of the available evidence on the detrimental effects of RV apical pacing. Furthermore, the available alternatives for patients with a standard pacemaker indication will be discussed. In particular, the role of cardiac resynchronization therapy and alternative RV pacing sites in these patients will be reviewed.
ObjectivePharmacological options for patients with a failing systemic right ventricle (RV) in the context of transposition of the great arteries (TGA) after atrial switch or congenitally corrected ...TGA (ccTGA) are not well defined. This study aims to investigate the feasibility and effects of sacubitril/valsartan treatment in a single-centre cohort of patients.MethodsData on all consecutive adult patients (n=20, mean age 46 years, 50% women) with a failing systemic RV in a biventricular circulation treated with sacubitril/valsartan in our centre are reported. Patients with a systemic RV ejection fraction of ≤35% who were symptomatic despite treatment with β-blocker and ACE-inhibitor/angiotensin II receptor-blockers were started on sacubitril/valsartan. This cohort underwent structural follow-up including echocardiography, exercise testing, laboratory investigations and quality of life (QOL) assessment.ResultsSix-month follow-up data were available in 18 out of 20 patients, including 12 (67%) patients with TGA after atrial switch and 6 (33%) patients with ccTGA. N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) decreased significantly (950–358 ng/L, p<0.001). Echocardiographic systemic RV fractional area change and global longitudinal strain showed small improvements (19%–22%, p<0.001 and −11% to −13%, p=0.014, respectively). The 6 min walking distance improved significantly from an average of 564 to 600 m (p=0.011). The QOL domains of cognitive function, sleep and vitality improved (p=0.015, p=0.007 and p=0.037, respectively).ConclusionsWe describe the first patient cohort with systemic RV failure treated with sacubitril/valsartan. Treatment appears feasible with improvements in NT-pro-BNP and echocardiographic function. Our positive results show the potential of sacubitril/valsartan for this patient population.
Objectives The purpose of this study was to assess left atrial (LA) strain during long-term follow-up after catheter ablation for atrial fibrillation and to find predictors for LA reverse remodeling. ...Background The association between LA reverse remodeling and improvement in LA strain after catheter ablation has not been investigated thus far. Methods In 148 patients undergoing catheter ablation for atrial fibrillation, LA volumes and LA strain were assessed with echocardiography at baseline and after a mean of 13.2 ± 6.7 months of follow-up. The study population was divided according to LA reverse remodeling at follow-up: responders were defined as patients who exhibited 15% or more reduction in maximum LA volume at long-term follow-up. Left atrial systolic (LAs) strain was assessed with tissue Doppler imaging. Results At follow-up, 93 patients (63%) were classified as responders, whereas 55 patients (37%) were nonresponders. At baseline, LAs strain was significantly higher in the responders as compared with the nonresponders (19 ± 8% vs. 14 ± 6%; p = 0.001). Among the responders, a significant increase in LAs strain was noted from baseline to follow-up (from 19 ± 8% to 22 ± 9%; p < 0.05), whereas no change was noted among the nonresponders. LAs strain at baseline was an independent predictor of LA reverse remodeling (odds ratio: 1.813; 95% confidence interval: 1.102 to 2.982; p = 0.019). Conclusions In the present study, 63% of the patients exhibited LA reverse remodeling after catheter ablation for atrial fibrillation, with a concomitant improvement in LA strain. LA strain at baseline was an independent predictor of LA reverse remodeling.
Combined Longitudinal and Radial Dyssynchrony Predicts Ventricular Response After Resynchronization Therapy John Gorcsan III, Masaki Tanabe, Gabe B. Bleeker, Matthew S. Suffoletto, Nini C. Thomas, ...Samir Saba, Laurens F. Tops, Martin J. Schalij, Jeroen J. Bax A combined echocardiographic assessment of longitudinal dyssynchrony by tissue Doppler imaging velocity and radial dyssynchrony by speckle-tracking strain was evaluated to predict ejection fraction (EF) response to cardiac resynchronization therapy (CRT) in 176 patients. When both 2-site longitudinal dyssynchrony (≥60 ms) and radial dyssynchrony (≥130 ms) were positive, 95% of patients had an EF response. When both were negative for dyssynchrony, 21% of patients had an EF response (p < 0.001 vs. both positive). When either was positive, but not both, 59% of patients had an EF response. Combined longitudinal and radial dyssynchrony patterns were more predictive of EF response after CRT than either alone (p < 0.0001).
As a consequence of improved technology, there is growing clinical interest in the use of multi-detector row computed tomography (MDCT) for non-invasive coronary angiography. Indeed, the accuracy of ...MDCT to detect or exclude coronary artery stenoses has been high in many published studies. This report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT (WG 5) of the European Society of Cardiology and the European Council of Nuclear Cardiology summarizes the present state of cardiac CT technology, as well as the currently available data concerning its accuracy and applicability in certain clinical situations. Besides coronary CT angiography, the use of CT for the assessment of cardiac morphology and function, evaluation of perfusion and viability, and analysis of heart valves is discussed. In addition, recommendations for clinical applications of cardiac CT imaging are given and limitations of the technique are described.
Transcatheter aortic valve replacement (TAVR) required precise knowledge of the anatomic dimensions and physical characteristics of the aortic valve, annulus, and aortic root. Most groups currently ...use angiography, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE) to assess aortic annulus dimensions and anatomy. However, multislice computed tomography (MSCT) may allow more detailed 3-dimensional assessment of the aortic root. Twenty-six patients referred for TAVR underwent MSCT. Scans were also obtained for 18 patients after TAVR. All patients underwent pre- and postprocedural aortic root angiography, TTE, and TEE. Mean differences in measured aortic annular diameters were 1.1 mm (95% confidence interval 0.5, 1.8) for calibrated angiography and TTE, −0.9 mm (95% confidence interval −1.7, −0.1 mm) for TTE and TEE, −0.3 mm (95% confidence interval −1.1, 0.6 mm) for MSCT (sagittal) and TTE, and −1.2 mm (95% confidence interval −2.2, −0.2 mm) for MSCT (sagittal) and TEE. Coronal systolic measurements using MSCT, which corresponded to angiographic orientation, were 3.2 mm (1st and 3rd quartiles 2.6, 3.9) larger than sagittal systolic measurements, which were in the same anatomic plane as standard TTE and TEE views. There was no significant association between either shape of the aortic annulus or amount of aortic valve calcium and development of perivalvular aortic regurgitation. After TAVR, the prosthesis extended to or beyond the inferior border of the left main ostium in 9 of 18 patients (50%), and in 11 patients (61%), valvular calcium was <5 mm from the left main ostium. In conclusion, MSCT identified that the aortic annulus was commonly eccentric and often oval. This may in part explain the small, but clinically insignificant, differences in measured aortic annular diameters with other imaging modalities. MSCT after TAVR showed close proximity of both the prosthesis and displaced valvular calcium to the left main ostium in most patients. Neither eccentricity nor calcific deposits appeared to contribute significantly to severity of paravalvular regurgitation after TAVR.
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